Failure to Perform Adequate Post-Fall Assessment and Safe Transfer, Resulting in Delayed Fracture Diagnosis
Summary
The deficiency involves the facility’s failure to provide care and services in accordance with professional standards of practice for one resident following a fall from bed during incontinent care. The resident was an elderly female with hemiplegia, severe cognitive impairment (BIMS score of 03), COPD, and convulsions, who was totally dependent on staff for transfers, bed mobility, and hygiene, and care planned to require a Hoyer lift with two staff for transfers. On the day of the incident, a CNA turned the resident onto her right side for incontinent care, then let go of the resident to pick up supplies from the floor. Video footage showed that, after the CNA released her, the resident rolled off the bed and onto the floor. The CNA then climbed across the bed and attempted to lift the resident by her arms to put her back in bed, was unable to do so, and lowered her back to the floor before calling for a nurse. Video footage and staff interviews showed that when two LVNs entered the room, the resident was still on the floor. One LVN placed a pillow under the resident’s head, and when the third nurse (the LVN who later documented the incident) arrived, the two LVNs and the CNA lifted the resident from the floor by her shoulders and knees and placed her back in bed, despite the resident being care planned for Hoyer lift transfers. The video showed that this was done without a proper assessment for injury while the resident was still on the floor. The documenting LVN’s progress note stated that the resident was checked for injuries and none were noted except blanchable redness on the right arm, and that the resident was assisted back to bed by two staff. However, the video evidence and subsequent interviews indicated that the assessment was cursory, that the resident was manually lifted contrary to her care plan, and that the nurse later acknowledged her assessment was not appropriate and that a Hoyer lift should have been used. In the days following the fall, multiple opportunities to identify and respond to signs of injury were missed. Hospice notes on two separate visits documented mild pain using the PAINAD scale, and the resident was noted to be at high risk for falls. A skin assessment completed several days after the fall documented no alterations in skin integrity, despite later photographic and video evidence showing progressive swelling and discoloration of the right lower leg and foot beginning shortly after the fall. Pictures and video from the resident’s room over several days showed swelling and yellow discoloration of the right lower leg and foot, and staff were heard discussing the resident’s facial grimacing as a sign of pain. CNAs later reported that they either did not notice or did not report the swelling, discoloration, or bruising, and one CNA acknowledged seeing bruising on the resident’s upper arm but not reporting it. Nursing notes eventually documented edema, warmth, discoloration, and pain responses in the right lower extremity, leading to hospice notification, an x-ray order, and the discovery of minimally displaced fractures of the distal tibia and mid fibula approximately one week after the fall. The facility’s own falls and acute change policies required thorough post-fall assessment, monitoring for delayed complications such as late fractures, and CNA reporting of subtle changes, but interviews and records showed that these assessments and communications were not consistently carried out for this resident. The deficiency also included failures related to care planning and communication of the resident’s care needs for bed mobility and incontinent care. The resident’s care plan identified total assistance needs for ADLs and the requirement for a Hoyer lift with two staff for transfers, but the actual care provided during and after the fall did not follow these directives. The CNA performed incontinent care without ensuring the resident was safely positioned in the middle of the bed and with supplies within reach, then left the resident unsupported on her side, resulting in the fall. After the fall, staff manually lifted the resident from the floor to the bed instead of using a Hoyer lift, despite being aware of her transfer status. Several staff, including the DON and Medical Director, acknowledged in interviews that they had not fully reviewed or acted upon video evidence or early signs of injury, and the Medical Director stated he had not been notified of increased pain, swelling, or discoloration in time to order earlier diagnostic testing. These combined actions and inactions led surveyors to identify an Immediate Jeopardy situation related to failure to assess for injury after the fall, failure to address bed mobility and incontinent care needs, and failure to transfer the resident back to bed using the required Hoyer lift. The facility’s own policies on falls and acute condition changes required nurses to assess vital signs, musculoskeletal function, neurological status, cognition, and pain after a fall, and to monitor for delayed complications such as late fractures and major bruising. Policies also required that direct care staff be trained to recognize and report subtle but significant changes, such as changes in skin color or condition. Despite these policies, the record and interviews showed that the resident’s post-fall assessments were incomplete, that weekly and ongoing skin assessments did not capture obvious swelling and discoloration documented in photos and video, and that CNAs did not consistently report observed or suspected pain, bruising, or changes in the resident’s condition to nursing staff. The combination of improper handling during and after the fall, failure to follow the resident’s care plan for transfers and bed mobility, and failure to recognize and act on evolving signs of injury over several days formed the basis of the cited deficiency. Additionally, the report documents that video evidence of the fall and subsequent handling was available to certain staff members but was not promptly escalated to facility leadership. A family member stated that video footage of the fall was sent to the documenting LVN on the day of the incident, and that she believed there was no other incident that could have caused the fractures. The ADON reported seeing only a brief portion of the video days later and stated that, had she seen all of it, she would have terminated the CNA at that time. The hospice RN reported showing the video to the DON several days after the fall, and the DON acknowledged reviewing the video but not reporting what she saw to the Administrator. The Administrator and Medical Director both stated they had not seen the videos until they were reviewed with the surveyor. This failure to fully review and act upon available video evidence contributed to delays in recognizing the severity of the incident and in addressing the resident’s injuries and care needs. The surveyors concluded that the facility failed in three key areas for this resident: assessing for injury following the fall from bed during incontinent care, addressing care needs for bed mobility and incontinent care in accordance with the care plan, and transferring the resident back to bed using a Hoyer lift as required. These failures were supported by video footage, interviews, and record review, including documentation of delayed recognition of swelling, discoloration, and pain in the right lower extremity, and the eventual diagnosis of tibia and fibula fractures one week after the fall. The Immediate Jeopardy was identified based on these findings, and although it was later removed, the facility remained out of compliance at a lower scope and severity because not all staff had been trained on key assessment and reporting processes at the time of the survey. The nursing home is disputing this citation, and the Medical Director stated he could not determine how the fractures occurred. However, the family member who reviewed all video footage from the date of the fall through the date of diagnosis reported that there was no other incident that would have caused the fractures. The survey findings relied on the combination of video evidence, staff statements, medical records, and facility policies to support the conclusion that the resident did not receive care and services in accordance with professional standards of practice in the areas of post-fall assessment, adherence to transfer and mobility care plans, and recognition and reporting of changes in condition following the fall.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with insulin-dependent type 2 DM and mild cognitive impairment had a rapid BG drop after receiving sliding scale insulin. The resident reported fear of overnight hypoglycemia and requested BG checks every 2 hours, but the record did not show overnight monitoring, reassessment, or follow-up. Staff later stated the night nurse was notified, while the resident said BG was not checked again until breakfast.
Failure to provide ordered wound care and aspiration precautions: A resident returned from a dermatology procedure with biopsy-site dressings and the chart lacked documentation of assessment or wound care, while the dressings remained in place and undated during observations. The same resident also had dysphagia with a FEES showing silent penetration with straw sips and an order for no straws, yet was observed drinking water from a cup with a straw; the SLP and DON confirmed the no-straw precaution and expectation to follow physician orders.
Failure to Monitor Ordered Vital Signs: A resident with COPD, chronic respiratory failure with hypoxia, and CHF had a provider order for daily vital signs, but the MAR showed an O2 sat of 87% with no follow-up vitals documented and another day with no vitals documented at all. Nursing notes did not show follow-up monitoring or documentation of the low O2 reading, and the CNO stated vitals were recorded on the night shift but not entered into the record or explained when the day-shift vitals were not completed as ordered.
Medication Administered Despite Hold Parameters: A resident with HTN and hyperlipidemia had an order for midodrine with BP hold parameters, but licensed nurses administered the medication multiple times even when the resident's BP met or exceeded the ordered limits. MAR review showed doses were given despite systolic and/or diastolic readings at or above the hold threshold, and the NHA acknowledged the medication was administered contrary to the physician's parameters.
Failure to assess and report abnormal blood glucose and document change in condition: The facility did not notify the MD of abnormal CBG results or assess for hypo/hyperglycemia for two residents with DM who had insulin orders and abnormal readings, including low and high values. The record also showed inaccurate documentation for another resident with a bruise of unknown origin that was monitored briefly and then no longer documented.
A facility failed to notify the provider about a resident’s weight changes per physician order. The resident had CAD, HF, HTN, and dementia, and the record showed weight fluctuations of 4 lbs and 5 lbs, but there was no evidence the provider was updated. The DON confirmed the provider was never notified and stated the provider should have been informed per the order.
Failure to Monitor Blood Glucose After Rapid Drop
Penalty
Summary
The facility failed to provide the care and services needed to safely manage diabetes for one resident with insulin-dependent type 2 diabetes and mild cognitive impairment. The resident’s care plan directed staff to monitor for signs and symptoms of high and low blood sugar, check blood glucose as ordered, administer scheduled and sliding scale insulin as ordered, encourage bedtime diabetic snacks, and provide ongoing diabetic foot care. On 7/15/26 at 12:25 a.m., the resident had a blood glucose of 330 before dinner and received 4 units of sliding scale insulin as ordered. The resident expressed concern about receiving the full insulin dose because of fear that blood sugar would drop during the night. About one hour later, the resident’s blood glucose decreased to 97. Staff gave 15 grams of carbohydrates and one glass of juice, and the blood glucose increased to 160. The resident then requested blood glucose checks every two hours during the night because of fear that blood sugar would fall below 50, and the nurse documented that the night nurse was notified. However, the medical record did not identify blood glucose monitoring, reassessment, or follow-up during the night. During interviews, the resident stated staff did not check blood sugar until breakfast the next morning and said, "They don't like checking it." Staff and the DON stated residents’ concerns should be documented and reassurance provided when blood sugar concerns were expressed.
Failure to Provide Ordered Wound Care and Aspiration Precautions
Penalty
Summary
The facility failed to provide timely post-procedure wound care for a resident who returned from a dermatology visit after a skin growth evaluation and treatment. The resident came back with dressings covering biopsy sites on the head and face, and the dermatology visit summary instructed staff to allow the pressure dressing to remain in place for 24 hours, then remove it, clean the wound daily with mild soap and water, pat dry, apply white petrolatum, and cover with a Band-Aid until healed. During observations on two consecutive days, the resident was still seen in bed with the dressings on the biopsy sites, and the dressings were not dated. The record contained no documentation that the biopsy sites were assessed upon return from the procedure and no documentation that wound care was performed on either day. The facility also failed to follow physician-ordered aspiration precautions for a resident with dysphagia. A FEES showed silent penetration with straw sips of thin liquids, and the resident was ordered an easy-to-chew diet with no straws. The care plan also directed staff not to provide beverages with a straw. Despite this, the resident was observed drinking water from a cup containing a straw. A CNA stated, "Well how else are we supposed to give him a water cup, we have to provide water." The SLP confirmed the FEES findings and the no-straw precaution, and the Medical Director stated he expected staff to follow physician orders and aspiration precautions for residents with dysphagia.
Failure to Monitor Ordered Vital Signs
Penalty
Summary
The facility failed to monitor vital signs as ordered by the physician for Resident #46, who was admitted with multiple diagnoses including COPD with acute exacerbation, chronic respiratory failure with hypoxia, and congestive heart failure. The facility policy titled Vital Signs stated that vital signs are to be taken as ordered by the provider and documented immediately after measurement, and that abnormal or concerning vital signs must be reported to the licensed nurse for assessment and intervention. A physician order dated 5/19/26 directed that Resident #46's vital signs be taken once daily during the day shift. The June 2026 MAR documented an oxygen saturation of 87% on 6/5/26 with no follow-up vital signs documented, and no vital signs documented on 6/6/26. The resident's nursing progress notes did not document follow-up vital sign monitoring or that the oxygen saturation was below 88%. The CNO stated that there was no documentation of follow-up measures or monitoring related to the low oxygen reading on 6/5/26, and that on 6/6/26 the night shift recorded vitals but did not enter them into the medical record or document why the vitals were not taken during the day shift as ordered.
Medication Administered Despite Hold Parameters
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards of quality by not ensuring licensed nurses administered medications according to physician-ordered parameters for one resident. The resident had diagnoses including hypertension and hyperlipidemia. A physician order dated June 24, 2026, directed midodrine 10 mg by mouth three times daily, with instructions to hold the medication if systolic blood pressure was greater than or equal to 120 mmHg or if diastolic blood pressure was greater than or equal to 80 mmHg. Review of the medication administration record and documented blood pressure readings showed staff administered midodrine on multiple occasions even though the resident's blood pressure met or exceeded the ordered hold parameters. The medication was given when blood pressure readings included 125/72, 125/74, 122/80, 112/80, 126/66, 122/68, 126/68, and 126/68. During an interview, the Nursing Home Administrator acknowledged that staff administered the medication despite blood pressure readings that met the physician's ordered parameters requiring the medication to be withheld.
Failure to Assess and Report Abnormal Blood Glucose and Document Resident Change in Condition
Penalty
Summary
The facility failed to notify the physician of increased and decreased capillary blood glucose (CBG) levels and failed to assess residents for hyperglycemia and hypoglycemia, as well as changes in physical assessment, for three residents. Facility policy for hypoglycemia required timely initiation of emergency treatment using approved protocols, and the general documentation policy required accurate, timely documentation of resident status, interventions, and notification of appropriate parties. The facility did not have a specific hyperglycemia policy and relied on physician orders for parameters. Resident R3 had diagnoses including hypertension, diabetes, cerebrovascular accident, and dementia. Physician orders included Lantus 30 units at bedtime and Novolog 6 units with meals, along with sliding scale insulin. The eMAR showed CBG readings of 70 and 67, and the record indicated the resident was not assessed for hyperglycemia or hypoglycemia, blood glucose was not monitored for effectiveness of treatment, care plan interventions were not followed, and the physician was not notified of the abnormal results. Resident R137 had diagnoses including hypertension, diabetes, muscle weakness, and cognitive communication deficit. Orders included checking blood sugars as needed for signs and symptoms of hypo- or hyperglycemia, rechecking blood sugars over 350 in 4 hours, fasting blood sugars every morning, post-prandial blood sugars, and Novolog 25 units with breakfast and lunch plus sliding scale coverage. The eMAR showed blood glucose values of LOW, 432, 45, and 0, and the record indicated the resident was not assessed for hyperglycemia or hypoglycemia, blood glucose was not monitored for effectiveness of treatment, care plan interventions were not followed, and the physician was not notified. Resident R11’s record showed a bruise to the left eye/brow with unknown origin, continued monitoring notes, and then no further documentation about whether the bruise resolved; the Nursing Home Administrator confirmed the facility failed to document accurately for this resident.
Failure to Notify Provider of Significant Weight Changes
Penalty
Summary
The facility failed to update the provider about resident R8’s weight changes per physician order. R8’s record showed diagnoses including coronary artery disease, heart failure, hypertension, and dementia, and the annual MDS indicated R8 was mildly cognitively impaired. A physician order dated 7-9-26 directed daily weights and to report a change of 3 lbs overnight. The weight record showed a 4 lb decrease from 153.5 lbs to 149.5 lbs and a 5 lb increase from 148.5 lbs to 153.5 lbs, but the medical record lacked evidence that the provider was ever notified of these changes. The DON confirmed by email that the provider was never updated, and later stated the provider should have been notified per the order.
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